Baby Tile – NCIU – Pref – BC Women's Health Foundation

$ Donation Amount:

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Baby's First and Middle Names *

Baby's Last Name *

Baby's Birthdate

Baby's Weight

Baby's Gender

Second Language Name Request (+ $35 extra) Yes No

Second Language Name

Second Language Name Optional Upload (image or PDF files only)

Select File(s)

Tile Type *

Would you consider sharing your BC Women’s story? If so, please summarize your story here:

Special Placement (+ $50 extra) Yes No

Special Placement Location

Your First Name

Your Last Name

Relationship to Baby

Additional Comments

Parent Information - Same as above? Same Information

Parents' Name(s)

Parent's Country

Parent's Address

Parent's Unit (if applicable)

Parent's City

Parent's Province

Parent's Zip / Postal Code

Parent's Phone Number

Parent's Email

Address + Phone

Country *

Address 1 *

City *

State / Province *

Zip / Postal Code *

Phone Number *

Payment

Personal Info

Title

First Name *

Last Name

Company Name

Email Address *

Make this an anonymous donation.

Comment

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Billing Details

Country *

Address 1 *

Address 2

City *

Province *

Zip / Postal Code *

Donation Total: $300.00

Baby Tile – NCIU – Pref

Address + Phone

Normalizing Recurrent Pregnancy Loss

“What Gets Measured Gets Done”

“Women’s Health Needs To Be Front and Centre”